Basic Information
| Provider Information | |||||||||
| NPI: | 1477690899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | BRUTZ | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4908 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082091027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 HOSPITAL WAY | ||||||||
| Address2: | SUITE D, SUITE 201 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084782472 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-166 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PAJ81 | 01 | ID | BCS | OTHER | 004392500 | 05 | ID | MEDICAID |